UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Cheyenne Nuttbrock |

|MSI & MSII Patient Assessment Tool . |Assignment Date: March 8, 2016 |

| ( 1 PATIENT INFORMATION |Agency: SMH UD |

|Patient Initials: JH |Age: 92 |Admission Date: March 4, 2016 |

|Gender: M |Marital Status: Widowed |Primary Medical Diagnosis: Stroke Alert |

|Primary Language: English | |

|Level of Education: 2 years undergraduate |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Retired from plant manager at a private college |Atrial Fibrillation |

|Number/ages children/siblings: A brother and a sister who are | |

|both deceased; 64 year old daughter; 69 year old daughter | |

|Served/Veteran: Yes in WWII |Code Status: DNR |

|If yes: Ever deployed? Yes or No | |

|Living Arrangements: Lives in Pennsylvania in an attached |Advanced Directives: Has a living will |

| |If no, do they want to fill them out? |

|house with a home health aide |Surgery Date: 3/4/2016 Procedure: CT scan |

|Culture/ Ethnicity /Nationality: Caucasian |of head; found old left frontal and right temporoparietal infarct |

|Religion: Roman Catholic |Type of Insurance: Self pay; Medicare |

|( 1 CHIEF COMPLAINT: Left-sided weakness |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) Patient is a 92 year old male who spends 3 months in |

|the winter in Florida with his daughter. He lives independently, |

|but does have a home health aide. The patient apparently took an extra dose of carvedilol this morning along with his |

|regular dose of digoxin. He was then noted at around 8:15 or 8:30 to have an acute onset of left-sided weakness. He |

|could not ambulate with the left leg. They also noted a left facial droop and slurred speech. The patient was brought to the |

|ED as a stroke alert. He was seen by neurology and deemed not to be a candidate for TPA. His symptoms were starting to |

|resolve. We were then asked to admit the patient primarily. He was seen down in the ED in the presence of his daughter |

|and son-in-law. They state he is basically back to baseline. He does have some slight left-sided facial droop noted, but |

|they tell me that is pretty much how he always is. The patient is very hard of hearing, but at this time has no complaints. |

|He does have Atrial Fibrillation and is on Coumadin. |

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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease

|Date |Operation or Illness |

|11-26-2009 |Diagnosed with ALOC (altered level of consciousness) |

|12-01-2009 |Cerebral bleed |

|2011 |Diagnosed with hypertension |

|2011 |Diagnosed with coronary artery disease |

|2011 |Diagnosed with dilated cardiomyopathy |

|2011 |Diagnosed with diabetes mellitus type 2 |

|1998 |Appendectomy |

|1998 |Coronary angiography |

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|( 2 FAMILY MEDICAL HISTORY |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations |X | |

|Routine adult vaccinations for military or federal service |X | |

|Adult Diphtheria (Date) U |X | |

|Adult Tetanus (Date) Is within 10 years? U |X | |

|Influenza (flu) (Date) Is within 1 years? Yes; in 2015 |X | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? U |X | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | |X |

If yes: give date, can state “U” for the patient not knowing date received

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |NO MEDICATION ALLERGIES |NO MEDICATION ALLERGIES |

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|Other (food, tape, latex, dye, |Environmental |Runny nose, itchy/watery eyes, congestion |

|etc.) | | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment) Many genes have been associated with type 2 diabetes, including those that code for beta-cell |

|mass, |

|beta-cell function, proinsulin and insulin molecular structures, insulin receptors, hepatic synthesis of glucose, glucagon |

|synthesis, and cellular responsiveness to insulin stimulation. Insulin resistance is associated with obesity and is the |

|defining factor of type 2 diabetes. Compensatory hyperinsulinemia prevents the clinical appearance of diabetes for many |

|years, but soon enough beta-cell dysfunction develops and leads to a relative deficiency of insulin activity. A progressive |

|decrease in the weight and number of beta cells occurs and many of the remaining cells develop exhaustion from an |

|increase in demand for insulin biosynthesis. The most prevalent risk factors associated with type 2 diabetes are age |

|(typically older than 30), obesity, family history, hypertension, and physical inactivity. In order to diagnose someone with |

|diabetes mellitus the physician would have to note the patients hemoglobin A1C count as greater than or equal to 6.5%, |

|the fasting blood glucose as greater than or equal to 126 mg/dl, the 2-hr plasma glucose as greater than or equal to 200 |

|mg/dl, or note that an individual with symptoms of hyper/hypoglycemia has a random plasma glucose of greater than or |

|equal to 200 mg/dl. Dietary measures and exercise are vital for the prevention and treatment of type 2 diabetes. Oral |

|hypoglycemic medications are also needed in order to optimize the treatment for individuals with type 2 diabetes. Insulin |

|therapy may also be needed in the later stages of type 2 diabetes due to an increase in the loss of beta cell function. |

|(Huether, 2012) |

( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]

|Name aspirin (Bayer Aspirin) |Concentration 325 mg |Dosage Amount 1 tablet |

|Route PO |Frequency Daily |

|Pharmaceutical class Salicylate |Home Hospital or Both |

|Indication Prophylaxis of transient ischemic attacks and MI; inflammatory disorders; mild to moderate pain; fever |

|Adverse/ Side effects GI bleeding, dyspepsia, epigastric distress, nausea, anaphylaxis, laryngeal edema, tinnitus |

|Nursing considerations/ Patient Teaching avoid concurrent use of alcohol to minimize gastric irritation, report tinnitus, report unusual bleeding of the gums, |

|report fever lasting longer than 3 days |

|Name atorvastatin (Lipitor) |Concentration 20 mg |Dosage Amount 1 tablet |

|Route PO |Frequency QHS (every night) |

|Pharmaceutical class HMG COA reductase inhibitor |Home Hospital or Both |

|Indication Adjunctive management of primary hypercholesterolemia and mixed dyslipidemia; primary prevention of CAD in asymptomatic patients with increased total |

|and low-density lipoprotein cholesterol and decrease high-density lipoprotein cholesterol |

|Adverse/ Side effects abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, rhabdomyolysis, angioneurotic edema |

|Nursing considerations/ Patient Teaching Notify the health provider if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever |

|or malaise; the medication should be used in conjunction with diet restrictions, exercise, and cessation of smoking |

|Name carvedilol (Coreg) |Concentration 3.125 mg |Dosage Amount 1 tablet |

|Route PO |Frequency BID (twice a day) |

|Pharmaceutical class Beta blocker |Home Hospital or Both |

|Indication Hypertension, heart failure, left ventricular dysfunction and myocardial infarction |

|Adverse/ Side effects Dizziness, fatigue, weakness, bradycardia, pulmonary edema, diarrhea, erectile dysfunction, Stevens-Johnson syndrome, toxic epidermal |

|necrolysis, hyperglycemia, anaphylaxis, angioedema |

|Nursing considerations/ Patient Teaching Abrupt withdrawal may precipitate life-threatening arrhythmias, hypertension, or myocardial ischemia; advise patient to |

|notify health care provider if slow pulse, difficulty breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash, fever, sore throat, unusual|

|bleeding, or bruising occurs; patients with diabetes should closely monitor blood glucose |

|Name cephalexin (Keflex) |Concentration 500 mg |Dosage Amount 1 capsule |

|Route PO |Frequency QID (4 times a day) |

|Pharmaceutical class First generation cephalosporin |Home Hospital or Both |

|Indication Skin and skin structure infections, respiratory tract infections, otitis media, urinary tract infections, and bone infections |

|Adverse/ Side effects Seizures (high doses), clostridium deficile-associated diarrhea, diarrhea, nausea, vomiting, abdominal pain |

|Nursing considerations/ Patient Teaching Instruct patient to notify health care professional if fever and diarrhea develop, especially if diarrhea contains blood, |

|mucus, or pus; instruct patient to report signs of superinfection (furry overgrowth on tongue and loose or foul smelling stools) and allergy |

|Name cetirizine (Zyrtec) |Concentration 10 mg |Dosage Amount 1 tablet |

|Route PO |Frequency Daily |

|Pharmaceutical class Piperazine |Home Hospital or Both |

|Indication Relief of allergic symptoms caused by histamine release including seasonal and perennial allergic rhinitis and chronic urticaria |

|Adverse/ Side effects Dizziness, drowsiness, fatigue, pharyngitis, dry mouth |

|Nursing considerations/ Patient Teaching May cause dizziness and drowsiness so caution patient to avoid driving or other activities requiring alertness; advise |

|patient to avoid taking alcohol or other CNS depressants; advise patient that good oral hygiene, frequent rinsing of mouth with water, and sugarless gum or candy |

|may minimize dry mouth; instruct patient to contact health care provider if dizziness occurs or if symptoms persist |

|Name finasteride (Proscar) |Concentration 5 mg |Dosage Amount 1 tablet |

|Route PO |Frequency Daily |

|Pharmaceutical class androgen inhibitor |Home Hospital or Both |

|Indication Benign prostatic hypertrophy and androgenic alopecia in men only |

|Adverse/ Side effects Prostate cancer, angioedema, breast cancer, gynecomastia, decreased libido, erectile dysfunction, infertility, decreased volume of ejaculate |

|Nursing considerations/ Patient Teaching Inform patient there is an increased risk of high grade prostate cancer in men taking this drug; advise patient to notify |

|health professional if changes in breasts occur; instruct patient to take medication as directed, even if symptoms improve or are unchanged |

|Name latanoprost (Xalatan) |Concentration 0.005% |Dosage Amount 1 drop in both eyes |

|Route Eyes |Frequency QHS (every night) |

|Pharmaceutical class Prostaglandin agonist |Home Hospital or Both |

|Indication Used to treat glaucoma or to lower intraocular pressure |

|Adverse/ Side effects Red, irritated eyes; red, painful, or swollen eyelids; rash or hives; seeing sparks or flashes of light; chest pain; stinging or burning |

|eyes; dry or watery eyes; blurred vision; eye sensitivity to light |

|Nursing considerations/ Patient Teaching Inform the patient the medication may change the color of their eyes to brown; Inform the patient to notify the health |

|care provider if their eye color begins to change or they become more sensitive to light; inform the patient to ask their doctor before using any other medicine; |

|inform the patient to not use any other eye drops at the same time as these eye drops; inform the patient to keep the bottle upright when the medication is not in|

|use and to throw away any unused eye drops after 6 weeks |

|Name warfarin (Coumadin) |Concentration 5 mg |Dosage Amount 1 tablet |

|Route PO |Frequency Daily |

|Pharmaceutical class Anticoagulant |Home Hospital or Both |

|Indication Prophylaxis and treatment of venous thrombosis, pulmonary embolism, and atrial fibrillation with embolization; management of myocardial infarction; and |

|prevention of thrombus formation and embolization after prosthetic valve replacement |

|Adverse/ Side effects Bleeding, dermal necrosis, cramps, nausea, fever |

|Nursing considerations/ Patient Teaching Advise patient to report any symptoms of unusual bleeding or bruising and pain, color, or temperature change to any area |

|of their body to a health professional immediately; Instruct patient not to drink alcohol or take other prescriptions, OTC, or herbal products, especially those |

|containing aspirin or NSAIDs, or to start or stop any new medications during warfarin therapy without the advice of a healthcare professional; emphasize the |

|importance of routine lab tests to monitor coagulation factors |

(Kee, 2015)

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Consistent carbohydrates |Analysis of home diet (Compare to “My Plate” and |

|Diet patient follows at home? Regular diet (“Nothing fancy”) |Consider co-morbidities and cultural considerations): |

| |According to (2016), this patient is eating 634 |

|24 HR average home diet: |calories over his daily limit of 2000 calories. The patient |

|Breakfast: Scrambled eggs and occasionally biscuits and |consumes 22 grams more saturated fat than recommended |

|gravy because it is his personal favorite |and almost 1000 more mg of sodium than normal. |

|Lunch: Soup with crackers or bread as a side |Considering the fact that this patient already has type 2 |

| |diabetes, hypertension, coronary artery disease, dilated |

|Dinner: States he eats seafood most of the time |cardiomyopathy, and is in his 90’s, he should really be |

| |making a change in his dietary choices. As noted in the |

|Snacks: Does not typically snack unless there is food |chart below, the patient is not consuming nearly enough |

|around, which he says is usually just mixed nuts |fruits and vegetables as he should be. I believe the patient |

|Liquids (include alcohol): Beer, scotch, gin, orange juice, |needs to receive some dietary education on eating a lower |

|milk, wine |fat and sodium diet with more fruits and vegetables added |

| |to it so that he can improve his functioning for the |

| |remainder of his life. I understand that he is nearing the |

| |end of his life and is most likely just attempting to enjoy it |

| |as much as he possibly can with the foods he has been |

| |consuming, but he should at least be receiving some |

| |education on the choices he has been making. His home |

| |health aide and daughters need to be educated as well so |

| |they can help him be as comfortable as possible for the rest |

| |of his life. |

|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as a reference.|

| |(MyPlate, 2016) |

| |[pic] |

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? Patient states his daughters help him when he is ill. |

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|How do you generally cope with stress? or What do you do when you are upset? Patient states he has an attitude that |

|things will improve and he feels as if he can deal with things when they get rough. |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|Patient states his leg being worked on has been difficult for him recently and the fact that he has been in the |

|hospital more in the last 2 to 3 years than he has been in the last 50 years has been hard. Patient also states he can |

|really not complain seeing as he has been healthy all these years.___________________________________________ |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |

|am going to ask some questions that help me to make sure that you are safe.” |

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|Have you ever felt unsafe in a close relationship? __No__ |

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|Have you ever been talked down to?_No_ Have you ever been hit punched or slapped?  __No__ |

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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  |

|_No_ If yes, have you sought help for this?  |

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|Are you currently in a safe relationship? Patient is no longer in a relationship because his wife passed away. |

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|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self-absorption/Stagnation X Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |

|patient’s age group: Ego integrity means someone over the age of 60 will be able to see their lifetime as a successful one, |

|whereas, someone who is in the stage of despair will be completely unsatisfied with their life and will blame themselves |

|for the way in which their life turned out. (McLeod, 2008) |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|The patient is in the stage of ego integrity in which one will look back on their life and be satisfied with all the things they |

|achieved. I came across this conclusion because my patient seemed as though he was ready to go when the time came. He |

|did not blame himself for his illness and was actually happy that he lived practically his whole entire life without any |

|major hospitalizations. My patient was also very positive when I asked him how he copes with his stress by stating that he |

|always has an attitude that things will improve and he feels as if he can deal with any obstacle that is thrown his way. |

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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|The patient did not seem to be impacted by his stroke alert hospitalization. He stated at one point in the interview that he |

|sees his health issues as easing him further into retirement. He could have easily been put into a depressive mood by this |

|particular health problem but he kept his head up through his entire stay. |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” The patient feels as though he did not exercise enough after he |

|retired and he knows he is getting older. |

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|What does your illness mean to you? In response to this question the patient states “I am happy I made it 90 years |

|without being sick but I feel like I am easing more into retirement.” |

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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

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|Have you ever been sexually active?_Yes_ |

|Do you prefer women, men or both genders? _Women_ |

|Are you aware of ever having a sexually transmitted infection? _No, never_ |

|Have you or a partner ever had an abnormal pap smear?_The patient never has and neither has his partner that he knows of_ Have you or your partner received the |

|Gardasil (HPV) vaccination? _No_ |

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|Are you currently sexually active?   _No_ If yes, are you in a monogamous relationship? _N/A_ When sexually active, what measures do you take to prevent acquiring |

|a sexually transmitted disease or an unintended pregnancy?  _Patient states he used to use condoms when he was still sexually active_ |

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|How long have you been with your current partner?_The patient has no current partner_ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  __The patient believes his age has impaired his ability to have sexual |

|activity__ |

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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|No |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?

The patient states he became a catholic because of his wife but they stopped going to the church because the religion relaxed its principles too much.

Do your religious beliefs influence your current condition?

No

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? N/A |How much?(specify daily amount) |For how many years? N/A |

| |N/A |(age N/A thru N/A) |

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|Pack Years: N/A | |If applicable, when did the patient quit? N/A |

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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? No|Has the patient ever tried to quit? N/A |

| |If yes, what did they use to try to quit? N/A |

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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? Gin, beer, scotch, wine |How much? “Not much anymore” |For how many years? 74 years |

| |Volume: 2 to 3 beers or glasses |(age 18 thru 92) |

| |Frequency: Only on the weekends | |

| If applicable, when did the patient quit? |when he eats dinner | |

| N/A |

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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? N/A |

| |How much? N/A |For how many years? N/A |

| | |(age N/A thru N/A ) |

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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

| |N/A | |

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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? No |

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|5. For Veterans: Have you had any kind of service related exposure? No |

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( 10 Review of Systems Narrative

| |Gastrointestinal |Immunologic |

| | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

|X Changes in appearance of skin | GERD Cholecystitis | Fever |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen N/A SPF: N/A | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: Bath once a day |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

|Be sure to answer the highlighted area |X Last colonoscopy? N/A | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary |X Anemia |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

|X Difficulty hearing | dysuria |X Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|X Nose bleeds | kidney stones |Blood type if known: N/A |

| Post-nasal drip |Normal frequency of urination: 5 x/day |Other: |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

|X Routine brushing of teeth 1 x/day | |X Diabetes Type: 2 |

| Routine dentist visits N/A x/year | | Hypothyroid /Hyperthyroid |

|Vision screening N/A | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

| Cough - dry or productive |Women Only | CVA |

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

| Pneumonia | Date of last gyn exam? | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

|X Environmental allergies | menarche age? | Encephalitis |

|X Last CXR? 2011 | menopause age? | Meningitis |

|Other: |Date of last Mammogram &Result: |Other: |

| |Date of DEXA Bone Density & Result: | |

|Cardiovascular |Men Only |Mental Illness |

|X Hypertension | Infection of male genitalia/prostate? | Depression |

|X Hyperlipidemia |X Frequency of prostate exam? 1 a year | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? 2015 | Anxiety |

|Myocardial Infarction |X BPH | Bipolar |

|X CAD/PVD |Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

|X Arrhythmias | Osteomyelitis | Scarlet Fever |

|X Last EKG screening, when? 3-8-16 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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|General Constitution |

|Recent weight loss or gain |

|How many lbs? N/A |

|Time frame? N/A |

|Intentional? N/A |

|How do you view your overall health? “Pretty good for being 92 years old” |

|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No |

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|Any other questions or comments that your patient would like you to know? No |

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|±10 PHYSICAL EXAMINATION: |

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|General Survey: Alert and oriented times 3 |

|Height 5 ft 10 in |

|Weight 145.12 lb |

|BMI 20.8 |

|Pain: (include rating and location) 0 |

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|Pulse 69 |

|Blood Pressure: (include location) |

|171/58 Arm |

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|Respirations 18 |

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|Temperature: (route taken?) 97.3 F oral |

|SpO2 96 |

|Is the patient on Room Air or O2 |

|Room air |

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|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

|X clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |

|X awake, calm, relaxed, interacts well with others, judgment intact |

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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |

|X clear, crisp diction |

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|Mood and Affect: X pleasant X cooperative X cheerful X talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary |

|X Skin is warm, dry, and intact X Skin turgor elastic No rashes, lesions, or deformities Contusions BUE |

|X Nails without clubbing X Capillary refill < 3 seconds X Hair evenly distributed, clean, without vermin |

|If anything is not checked, then use the blank spaces to |

|describe what was assessed in the physical exam that |

|was not WNL (within normal limits) |

| Central access device Type: N/A Location: N/A Date inserted: N/A |

|Fluids infusing? X no yes - what? |

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|HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline |

|X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge |

|X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

|X PERRLA pupil size / 3 mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus |

|X Ears symmetric without lesions or discharge Whisper test NOT heard: right ear- inches & left ear- inches |

|Nose without lesions or discharge (Rhino Rocket in left nostril) X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: Patient had all of his teeth in his mouth |

|Comments: |

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|Pulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric |

|X Percussion resonant throughout all lung fields, dull towards posterior bases |

|X Sputum production: thick thin Amount: scant small moderate large |

|Color: white pale yellow yellow dark yellow green gray light tan brown red |

|Lung sounds: Normal bilaterally |

|RUL CL LUL CL |

|RMLCL LLL CL |

|RLL CL |

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|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |

|Cardiovascular: X No lifts, heaves, or thrills |

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|Heart sounds: X S1 S2 audible Regular X Irregular A. Fib X No murmurs, clicks, or adventitious heart sounds X No JVD |

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|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

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|X Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

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|Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3 |

| |

|X No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm)] |

| |

|Location of edema: N/A pitting non-pitting |

| |

|X Extremities warm with capillary refill less than 3 seconds |

| |

| |

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|GI X Bowel sounds active x 4 quadrants; no bruits auscultated X No organomegaly |

| |

|X Percussion dull over liver and spleen and tympanic over stomach and intestine X Abdomen non-tender to palpation |

| |

|Last BM: (date 3/8/2016 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

| |

|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

| |

|Nausea emesis Describe if present: N/A |

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|Genitalia: Clean, moist, without discharge, lesions or odor X Not assessed, patient alert, oriented, denies problems |

| |

|Other – Describe: N/A |

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| |

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|GU Urine output: X Clear Cloudy Color: Yellow Previous 24 hour output: 1875 mLs |

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|Foley Catheter Urinal or Bedpan X Bathroom Privileges without assistance or with assistance |

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|X CVA punch without rebound tenderness |

| |

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|Musculoskeletal: X Full ROM intact in all extremities without crepitus |

| |

|Strength bilaterally equal at _4_ RUE _4_ LUE _3_ RLE & _4_ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

| |

|X Vertebral column without kyphosis or scoliosis |

| |

|X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia |

| |

| |

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|Neurological: X Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

| |

|X CN 2-12 grossly intact X Sensation intact to touch, pain, and vibration X Romberg’s Negative |

| |

|X Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride Small, short, shuffles across the floor when |

|ambulating |

| |

|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

| |

|Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +1 Achilles: +2 Ankle clonus: positive negative Babinski: positive |

|negative |

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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |

|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |

|is done preop) then include why you expect it to be done and what results you expect to see. |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|INR |

|1.89 H |

| |

|1.82 H |

|Normal (0.8-1.2) |

| |

|3-7-2016 |

| |

|3-8-2016 |

| |

|The patient’s INR values are trending high. This could be positive if the doctor is intending to start the patient on warfarin. |

|The normal INR range for warfarin therapy is from 2-3, so the fact that the patient’s INR levels are rising is positive. The doctor is most likely planning to start |

|the patient back on his warfarin soon. |

| |

|Platelets |

|78,400 L |

| |

|78,000 L |

|Normal (150,000-450,000) |

| |

|3-7-2016 |

| |

|3-8-2016 |

|The patient’s platelet count is trending low as each day progresses. This is an indication that the patient bleeds easily. |

|Being as the patient’s platelet count is low, this increases his risk of bleeding. This condition is called thrombocytopenia, which is most likely being caused by |

|the patient’s intake of aspirin and warfarin. |

| |

|Creatinine |

|1.45 H |

| |

|1.49 H |

|Normal for men (0.7-1.3) |

| |

|3-7-2016 |

| |

|3-8-2016 |

|The patient’s creatinine levels are increasingly rising as each day passes. This is an indication of the kidneys not functioning properly. |

|High creatinine levels can be caused by many factors and reveal the functioning capacity of the kidneys. In this patient’s case, his creatinine levels are most |

|likely high because he has lost a large amount of blood. This patient bleeds very easily and has been bleeding from his right forearm due to an injury in this area. |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing, multidisciplinary treatments and procedures, such as diet, vitals, activity, |

|scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.) |

|Vitals every 4 hours to monitor for changes in baseline, Accucheks 30 minutes after meals to monitor |

|glucose levels in relation to type 2 diabetes, consistent carbohydrates diet ordered in hospital to increase |

|energy levels, and OOB activity order Ad lib (with assistance) due to the patients shuffling gait. |

| |

|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

| |

|1. Impaired walking related to loss of balance and coordination as evidenced by shuffling gait (Ackley et al., 2014). |

| |

| |

| |

|2. Bathing self-care deficit related to decreased strength and endurance as evidenced by use of a home health aide |

| |

|(Ackley et al., 2014). |

| |

|3. Impaired memory related to neurological disturbances as evidenced by difficulty remembering certain aspects of |

| |

|the patients past (Ackley et al., 2014). |

| |

|4. |

| |

| |

| |

|5. |

| |

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| |

± 15 CARE PLAN

Nursing Diagnosis: Impaired walking related to loss of balance and coordination as evidenced by shuffling gait.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |

| | |Provide References | |

|Patient will demonstrate optimal independence and |Walk clients frequently with an appropriate number of|Standing/weight bearing benefits gut motility, |The patient is able to walk on his own with limited |

|safety in walking during his stay in the hospital and|people; have one team member state short, simple |spasticity, and respiratory/bowel/bladder function, |assistance during his stay in the hospital and once |

|once he is discharged |motor instructions. |and promotes muscle stretching. |he returns home. The patient and hospital staff |

| | | |undergo all safety precautions to prevent any |

| |Individualize interventions to prevent falls such as |The fall prevention program should include fall |falls/injuries during the patients stay in the |

| |scheduled toileting, monitored rooms, bed alarms, |prevention interventions as well as assessment of |hospital. |

| |wheelchair alarms, balance/strength training, sleep |risk and assessment of an actual fall. | |

| |hygiene, education on risk of medication/alcohol use,| | |

| |removal of hazards, and attention to safe handling | | |

| |during any transfers, toileting, showering/bathing. | | |

|Patient will demonstrate the ability to direct others|Use a snug gait belt with handles and assistive |A gait belt must be applied before and during all |The use of teaching and involving the patient in the |

|on how to assist with walking within a week of being |devices while walking clients, as recommended by the |ambulation and functional gait activities; it should |plan of care allows the patient to be able to explain|

|discharged from the hospital |physical therapist. |be applied securely around the waste. |to his family and home health aide how to assist him |

| | | |with walking. He is able to instruct them effectively|

| | |Communication and consistency promote client |after a week of being discharged. |

| |Document the number of helpers, level of assistance, |learning/safety, help prevent staff injury. Utilize | |

| |type of assistance, and devices needed on the care |all client handling and movement equipment as | |

| |plan and room white board. |possible. | |

|Patient will demonstrate the ability to properly and |Reinforce correct use of prescribed mobility devices |Canes are prescribed to improve gait, balance, and |During a 12 hour period, the patient correctly |

|safely use and care for assistive walking devices |and remind clients of weight-bearing restrictions. |alleviate joint pain and are usually used on the |utilizes all assistive walking devices ordered. |

|during this shift | |contralateral side of the affected limb. |Patient remains free from falls and injury during |

| | | |this shift. |

| | |This will help the patient when they return home so | |

| |Teach clients to check ambulation devices weekly for |that they monitor their devices, enhancing their | |

| |cracks, loose nuts, or worn tips and to clean dust |safety as a result. | |

| |and dirt on tips. | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Include a minimum of one | | | |

|Long term goal per care plan | | | |

|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult |

|□Dietary Consult |

|X PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|X F/U appointments |

|□Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|X Rehab/ HH |

|□Palliative Care |

(Ackley et al., 2014)

Nursing Diagnosis: Bathing self-care deficit related to decreased strength and endurance as evidenced by use of a home health aide.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |

| | |Provide References | |

|Patient will remain free of body odor and maintain |Consider using chlorhexidine-impregnated cloths |Chlorhexidine reduces hospital-acquired infection |The patient does not have any odor and his skin |

|intact skin during the course of this shift |rather than soap and water for daily client bathing. |risk from the potentially harmful pathogens MRSA and |remains intact for a 12 hour period. |

| | |VRE. | |

| | | | |

| |Consider using a prepackaged bath, especially for |Use of cleansing cloths avoids exposure to bath | |

| |high-risk clients, to avoid client exposure to |basins, contaminate tap water, cross-contamination | |

| |pathogens from contaminated bath basin, water source,|from use of one cloth to bathe the entire body, and | |

| |and release of skin flora into bath water. |contamination of sink and surrounding area from bath | |

| | |water disposal. | |

|Patient will bathe with assistance of caregiver as |Establish the goal of a client’s bath as being a |Sensations that make bathing pleasant should be used |Patient tolerates his bath well and remains |

|needed and report satisfaction, and dignity |pleasant experience, especially for cognitively |for everyone to avoid behaviors that are symptoms of |comfortable for the entire duration of the bath over |

|maintained during bathing experience during the |impaired clients, and plan for client preferences in |unpleasant bathing, which are often due to pain. |the course of a 12 hour period. |

|course of this shift |timing, type and length of bathing, water | | |

| |temperature, and with silence or music. | | |

| | | | |

| |Use a comfortable padded shower chair with foot |Unpadded shower chairs with large openings and no | |

| |support, or adapt a chair; pad it with |foot support contribute to pain by allowing clients | |

| |towels/washcloths, cover the cold back with dry |to sink into the opening with their feet unsupported.| |

| |towels, and cover the arms with foam pipe insulation.| | |

|Patient will use methods to bathe safely with minimal|Request referrals for occupational therapy for |After stroke, those receiving occupational therapy |Within a month of being discharged, the patient will |

|difficulty after one month of being discharged |clients who have experienced a stroke. |preserve more function and therefore are more likely |assist his home health aide in bathing himself to the|

| | |to be independent in performing activities of daily |best of his abilities. |

| | |living. | |

| | | | |

| | |Support by home health aides preserves the energy of | |

| |Based on functional assessment and rehabilitation |the client and provides respite for caregivers. | |

| |capacity, refer for home health aide services to | | |

| |assist with bathing and hygiene. | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Include a minimum of one | | | |

|Long term goal per care plan | | | |

|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult |

|□Dietary Consult |

|X PT/ OT |

|X Pastoral Care |

|□Durable Medical Needs |

|□F/U appointments |

|□Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|X Rehab/ HH |

|X Palliative Care |

(Ackley et al., 2014)

References

Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights, Missouri: Elsevier.

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO: Elsevier.

Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2015). Pharmacology: A patient-centered nursing process approach. St. Louis, MO: Elsevier/Saunders.

McLeod, S. (2008). Erik Erikson | Psychosocial Stages | Simply Psychology. Retrieved November 23, 2015, from

MyPlate (n.d.). Choose MyPlate. Retrieved March 19, 2016, from

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